Goal met. Pt was able to ambulate around the
nurses’ station by discharge.Pt was
able to complete his activity more than twice. Pt did not complain of any pain or
discomfort upon ambulation.

Pt states “I feel like I’m finally getting
back to my old self.”

Continue interventions as listed. Encourage
pt to continue the use of braces and assistive devices after discharge until he
feels comfortable c/o. Encourage the pt to continue his independence in ADLs and
c/o unnecessary assistance.

R/T:

Acute pain, secondary to fractured left femur

ORIF surgery

Anxiety

Musculosketeal impairment

Short Term:

Pt will perform passive range of motion exercises by the end of this shift.

*Assess the pt’s pain by using the 10 point pain rating scale q4 hrs or PRN.

Rationale:

“Single- item ratings of pain intensity are valid and reliable as measures of pain
intensity.”

“The client’s report of pain is the single most reliable indicator of pain.”